Electronic Capitation Reports
Provider Type
- Participating Physician Groups (PPG)
- Hospitals
Health Net provides commercial, Medicare Advantage (MA) capitation reports to capitated participating physician groups (PPGs) and hospitals on five electronic media files - Eligibility, Activity Analysis, Remittance Detail, Eligibility Summary by Group, and SB 260 Reconciliation Report.
Eligibility File
The Eligibility file lists all members eligible for benefits for at least one day in the month. It contains member information, including names, addresses, plan codes, and benefit information. Capitation amounts are not included in the file, but may be listed in the Remittance Detail file. The Eligibility file is sorted by the member's last name. All records in this file are 224 bytes long. There are four record types: header, detail, coordination of benefits (COB), and trailer. Data expressed in the X format is left-justified and blank-filled, data expressed in the nine format is right-justified and zero-filled.
Activity Analysis File
The Activity Analysis file provides non-dollar activity, such as additions and cancellations of members, and should be used to update members' files, including retroactive adjudication of affected claims. It also reflects changes to a member's status, such as plan code, address and effective date. Multiple transactions for a member are sorted by prioritization of activity codes and report by prioritization. The Activity Analysis file is sorted by the member's last name. All records in the file are 279 bytes long. There are three record types: header, detail and trailer. Data expressed in the X format is left-justified and blank-filled. Data expressed in the nine format is right-justified and zero-filled.
Remittance Detail File
The Remittance Detail file provides capitation remittance amounts per member. The amount reflected consists of the current month capitation amount plus any adjustments made in the current month for retroactivity. The Remittance Detail file is sorted by the member's last name. All records in this file are 157 bytes long. There are three record types: header, detail and trailer. Data expressed in the X format is left-justified and blank- filled. Data expressed in the nine format is right-justified and zero-filled. All dollar amount fields are signed (-, +) and contain assumed decimals.
Eligibility Summary by Group File
The Eligibility Summary by Group file lists all employer groups with active members enrolled with a specific provider for the month being reported. This file is sorted by the employer group name. All records in this file are 142 bytes long. This file has three record types: header, detail and trailer. Data expressed in the X format is left-justified and blank-filled. Data expressed in the nine format is right-justified and zero-filled.
SB 260 Reconciliation Report
The SB 260 Reconciliation Report provides enrollment and capitation payment summary at the product level for the prior 18 months. All records in this file are 1024 bytes long. This file has three record types: header, detail and trailer. Data expressed in the X format is left-justified and blank-filled. Data expressed in the nine format is right-justified and zero-filled.
Internet Transmission
Health Net also offers providers these five capitation reports through the Internet to help reconcile eligibility and remittance payments. PPGs and hospitals that request their capitation reports online are allowed to test their files for a period of up to two months and still receive hard copy reports. After this two-month testing period, hard copy reports are no longer sent. With the exception of this testing period, only one format of reports is provided. If PPGs or hospitals are interested in receiving capitation files in this format, they should contact their provider relations and contracting specialists for details.